A 47-year-old Caucasian male with a past medical history of 30 pack-year tobacco abuse and left lower extremity deep vein thrombosis (DVT) diagnosed a month prior to admission presented to the emergency room with right lower extremity swelling and superficial thrombophlebitis of right upper extremity of 10 days' duration. He had been on Coumadin since his initial DVT. INR at admit was subtherapeutic. Physical exam revealed palpable cords of the right upper and lower extremity and in the leg was associated with warmth, erythema, and edema. His only medications were Coumadin 5 mg po daily and Percocet prn for pain. The rest of his history and physical examination was unremarkable. An ultrasound scan of right lower extremity failed to reveal any deep vein thrombosis and his basic metabolic panel was within normal limits. His white count was elevated at 18.4 3 103 /μL with a differential of 79% polymorphonuclear leukocytes, 13% lymphocytes, and 4% monocytes and INR was 1.44. A work-up failed to reveal any abnormal lab including factor V Leiden, lupus anticoagulant, factor XII, ANA, rheumatoid factor, homocysteine, thyroid-stimulating hormone, homocysteine, or rapid plasma regain (RPR). As Trousseau's syndrome was considered a possibility a CT chest, abdomen, and pelvis was done to look for a primary malignancy that revealed bilateral pulmonary emboli as well as mediastinal and hilar adenopathy and thyroid nodules. The patient was fully anticoagulated with low-molecular-weight heparin. PET scan demonstrated uptake in the hilar and mediastinal node as well as a right supraclavicular node and the thyroid gland. There was no uptake that suggested a primary lung or abdominal/pelvic malignancy. As the supraclavicular node was too deep to be accessible a Chamberlain procedure was done and the mediastinal node in the aorticopulmonary window was biopsied. Pathology returned as positive for papillary carcinoma of undetermined primary. Special stains such as thyroid transcription factor 1 (TTF-1) and carcinoembryonic antigen (CEA) were positive but thyroglobulin and PSA were negative. An ultrasound of the thyroid revealed nodules that were biopsied and pathology revealed papillary carcinoma. In the absence of any other primary it was concluded that this was a case of Trousseau's syndrome secondary to papillary carcinoma of the thyroid and to our knowledge the first case described in the medical literature.
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